Long presentation

On
Hemorrhage and
shock

SUBMITTED TO, SUBMITTED BY,

MRS.PRASHANTHI MADAM,
CH.MOUNIKA,
ASST.PROFESOR M.SC [N] 1 st
YEAR,
GOVERNMENT COLLEGE OF NURSING
G.C.O.N,
HYDERABAD.
HYDERABAD.
STUDENT PROFILE :
Name of the subject : advance nursing practice
Name of the topic : HEMORRHAGE AND SHOCK
Group : m Sc 1 st year
Medium of instruction : English
Method of presentation : lecture cum discussion
Class : m sc 1 st year
Date and Time : 21/6/21
Venue : M.SC 1 year class room.
Duration : 1 hour
Name of the student : CH.MOUNIKA
Name of the supervisor : Mrs. PRASHANTHI madam
OBJECTIVES:
General Objectives:
At the end of the seminar, the students are able to gain in depth
knowledge and develop skills in management of Hemorrhage and shock.
Specific Objectives:
At the end of the seminar, students will be able to:
• review Anatomy and Physiology of circulatory system.
*Define Hemorrhage and shock.
• list out the types and its classifications.
• enumerate the causes and clinical manifestations of Hemorrhage and
compare clinical findings of the compensatory and progressive stages of
shock.
• describe the pathophysiology of Hemorrhage and shock.
*list out Diagnostic evaluations of Hemorrhage and shock.
*explain complications of Hemorrhage and shock.
• describe the importance of nutritional support in all forms of shock.
• Enumerate the management of Hemorrhage and shock.
Medical
Surgical
Nursing
• explain the prevention of Hemorrhage and shock.• describe the role of
the nurse in Psycho-social support of both the patient experiencing
shock and the family.
OUT LINE: -

• INTRODUCTION
• DEFINITION
• PATHOPHYSIOLOGY OF HAEMORRHAGE
• FACTORS AFFECTING CLOTTING
• CAUSES
• TYPES OF HAEMORRHAGE
1.ACCORDING TO THE TIME OF WOUND.
2.ACCORDING TO CLINICAL CLASSIFICATION OF THE
HAEMORRHAGE.
• SIGN AND SYMPTOMS OF HAEMORRHAGE
• EFFECTS OF HAEMORRHAGE
• MANAGEMENT /CONTROL OF HAEMORRHAGE
• FLUID REPLACEMENT DURING HAEMORRHAGE
• HAEMORRHAGE FROM SPECIAL SITES
INTRODUCTION
Hemorrhage is a bleeding Bleeding can occur internally (or) externally where
blood leaks form blood vessels inside the body (or) externally. Hemorthage is a
serious complication. Surgery that can result in death. Size of the Aneurysms
increases. There is a increased risk of rupture leads to hemombage. Hemorrhage
can occur during carly pregnancy (or) late pregnancy Eg: Placenta, Previa and
Placenta abruption, post partum hemorrhage, during labour

The world shock is used differently by the medical communities and the general
public the public used this term as an intense emotional reaction and medical
meaning is complex clinical. Syndrome and it is life functioning condition. Shock
can occur in association with many, kinds of major illness. such as hemombage
trauma, burns, infections and Heart disease.

Shock effects all body systems. It may develop rapidly (or) slowly depending on
the underlying cause.

During shock, the body struggles to survive, calling on all its homeostatic
mechanisms to restore blood flow and tissue perfusion. Therefore, almost any
patient with any disease state may be at risk for developing shock.

HEMORRHAGE

Hemorrhage is the loss of blood or blood escape from the circulatory

system. Bleeding can occur internally where blood leaks from blood vessels inside
the body or externally, either through a natural opening such as vagina, mouth,
nose, car and anus or through a break in the skin.

- Lewis
Escape of blood from an injured vessel

-Bailliers
Hemorrhage is a serious complication of surgery that can result in death. When
blood loss is extreme, the patient and apprehensive
 - Lippin cott
Bleeding is a common cause of death in accidents. It is caused by rupture of blood
vessels due to severity of the injury.

- First aid to the injured

Hemorrhage or bleeding is a flow of blood from an artery, vein or capillary.

Loss of blood (or) blood escape from the circulatory system.

-American and British spelling differences -

INCIDENCE:

 A healthy person can endure a loss of 10-15% of total blood volume without
serious medical difficulties.
 Blood donates typically takes 8-10% of donor's blood volume.
 Severity of condition mortality rate is 80%.

CAUSES:

Bleeding generally becomes dangerous or ever fatal, when it causes hypovolemia

(low blood volume)

• Hypertension
• Hemophilia
• -Homeostasis
• Thrombocytopenia (low platelet count)
• Anticoagulant medication like "warfarin"
• Ulcer's
• Atherosclerosis
• Crush injuries
• Hematoma
• Incisions
• Coagulation disorders
• Congenital defects
• Vascular malformations
 • Vit K deficiency
TYPES OF BLEEDING:
Class-1 Hemorrhage: It involves up to 15% of blood volume, No change vital signs
and fluid resuscitation is not necessary
Class-II Hemorrhage: Involves 15-30% of total blood volume. A patient
often tachycardia e narrowing difference between the systolic and diastole blood
pressure. Skin may look pale and cool to the touch.
Class-III Hemorrhage: Involves loss of 30-40% of blood volume B.P. drops. the
Heart rate increases shock, mental status, worsens, fluid resuscitation with
crystalloid and blood transfusion are usually necessary.
Class-IV Hemorrhage: Involves loss of >40% of circulating blood volume. The
limit of the body's compensation is reached and aggressive resuscitation is required
to prevent death.
Individuals in excellent physical and cardiovascular shape may have more
effective compensatory mechanisms before experiencing cardiovascular collapse.
These patients may look deceptively stable, with minimal derangements in vital
signs; while having poor.

Elderly patients as those with chronic medical conditions may have less tolerance
to blood loss, less ability to compensate, and may take medications such as beta
blockers that can potentially blunt the cardiovascular response care must be taken
in the assessment of those patients.

II. Clinically divided into:

1. External Hemorrhage:
Massive external bleeding is dramatic and distressing. Bleeding may be profuse
and copious. Shock may develop and the casualty may lose consciousness.
2. Internal Hemorrhage:
Bleeding within the body cavities may follow injury, such as fracture or
penetrating wound but can also occur spontaneously for Eg: Bleeding from a
stomach ulcer". Internal bleeding is serous even if blood is not split from.
the body it is still lost from the circulation and shock can develop Accumulated
blood can also exert damaging pressure on organs. Such as the lungs or brain sings
of shock develop without obvious blood loss. At the site of a violet injury, there
may be pattern bruising Discoloration with the pattern of clothes or crushing
objects. There may be blood at body orifices, either fresh or mixed with the
contents of injured organs.

III According to the kind of vessel involved :

1. Arterial Hemorrhage:
Hemorrhage from an artery in bright red in color appears in spurts with each
heart beat. The pressure of blood in the arteries in considerably high.
As the heart alternately contracts and ejects blood flow speeds up and slows
accordingly. When the heart contracts and ejects blood, the walls of elastic arteries
sweeter to accommodate the swage of blood. Bleeding form a cat artery or lead to
heavy blood loss
2. Venous Hemorrhage :
Veins do not contain the external or internal elastic found in arteries. Despite
there differences, veins are still distensible enough to adapt to variations on the
volume and pressure of blood passing through them. Also the lamer of a vein is
larger than that of a comparable artery under vein frequently appears collapsed.
When sectioned. Blood leaves a cat vein on a even, slow flow, it bubbles out
quickly and is dark in color.
3. Capillary Hemorrhage :
There is a ring of smooth muscle fiber called percapillary splinter that controls the
flow of blood entering a true capillary. Blood usually does not flow in a continuous
manner through capillary network .it flows intermittently b/c of contraction.
CLASSIFICATION OF HEMORRHAGE:

The Hemorrhage can be classified into

1. Traumatic injury
2. Aneurysms
3. Cerebral hemorrhage
4. Intracranial hemorrhage
5. Hematemesis
6. Hematuria
7. Early pregnancy bleeding (Anti partum hemorrhage)
8. Late pregnancy bleeding
9. Bleeding during labor (Intra pattern H)
10.After delivery (Post-partum Hemorrhage) 11. Upper gastro intestinal (GI)
bleeding.

CLINICAL MANIFESTATION OF HEMORRHAGE

 The clinical signs presented by Hemorrhage depend on the amount of blood

lost and how quickly it is lost.
 The patient is apprehensive and restless, moves continually and thirstly.
 The temp falls and respirations and rapid and deep, after of the gasping
  type spoken of hunger.
 If the hemorrhage progresses untreated cardiac output decrease and the
 hemoglobin of the blood falls rapidly.
 The lips and conjunctiva become pallor.
 Spots appear before the eyes.

 A ringing is hard in the cars.

 The patient grows weaker but remains conscious until near death.
 The Heart rate fse with weak and threapy pulse, cool, clammy, pale skin.
 When hemorrhage is internal the operative side becomes tight and swollen
Eg: If a client bleeds within the abdomen, it becomes tight and distended
 For internal bleeding
 Dizziness
 Headache, Chest pain
 Loss of appetite, Depression, Anxiety
EFFECTS OF HEMORRHAGE
On cardiovascular system
Reduced blood after hemorrhage decreases venous return, ventricular filling &
cardiac output.
During mild hemorrhage
during slow or mild hemorrhage when there is loss of a small amount of blood up
to 350-500 ml the blood pressure decreases slightly & soon it returns back to
normal.
During severe hemorrhage
when hemorrhge is severe with lost of about 1500 to 2000 ml of blood, the arterial
blood pressure falls to a great extend.
On skin
▸ Vasoconstriction
▸ It increases the deoxygenation of blood.
▸ It results pallor in color of skin. Sometimes cyanosis develops.
On tissue fluid
▸ arteriole constriction decreases the capillary pressure.
▸ It helps to compensates the blood loss.
On kidney
▸ constriction of afferent & efferent arterioles of kidney after hemorrhage
decreases the GFR very much, Therefore, the urinary output decreases.
On Renin secretion
▸ hypoxia produced after blood loss increases secretion of Renin from kidney &
the subsequent formation of Angiotensin 2.
▸ It also increases release of aldosterone from adrenal cortex.
▸ Aldosterone causes retention of sodium
On secretion of antidiuretic harmone
▸ ADH is released in large quantities immediately after the hemorrhage.
▸ It is probably due to increased osmolality of body fluid by aldosterone induced
sodium retention.
On respiration
▸ hemorrhage causes stagnant hypoxia because of decreases in venous return,
cardiac output.
On nervous system
1.on reticular formation
The catecholamine stimulates the reticular activating system. it causes restlessness,
anxiety and increased motar actvity after hemorrhage.
2. on brain
Through hemorrhage causes vasoconstriction in many organ of the body, it causes
vaso-dilation in brain.
3.Fainting
when hemorrhage is severe, cardiac output decreases & blood pressure falls. So,
the blood flow to brain decreases resulting in unconsciousness.
4. cerebral ischemia
when the blood flow to brain is severely affected due to hypoxia, ischemia of the
brain tissue develops within 5 minutes. It causes irreversible damage to brain
tissues
CONTROL OF EXTERNAL HEMORRHAE
1.Pad & Bandage
This is the simple method of applying direct pressure to a bleeding wound & is
applicable to vast majority of cases.
It is effective & causes no damage.
2.Digital pressure
It is the pressure applied on the point of artery supplying blood to the area of
wound.
This will control hemorrhage temporally & is called indirect pressure.
3.Elevation of the limb
It will control venous hemorrhage.
This is a classical method of dealing with a sudden hemorrhage from a suptured
varicose vein of leg
4.Application of tourniquet
A temporary tourniquet may have to be devised in sudden emergency.
It should be 3-4 inches wide.
The great danger of tourniquet is that if it is self on for more than 30 min then
gangrene of the limb may occur.
5.Surgical ligation
It is necessary if the bleeding is persistent.
6.coagulation: It can be used to coagulate the blood from small blood vessels.
7.Pack: It will temporarily control severe hemorrhage.
This method is used in operation theater to control temporary or sudden
hemorrhage.
8.styptics
These are also used to control bleeding & they act as astringents. Astringents such
as snake venom or adrenaline may be used locally in certain cases.

FIRST AID TREATMENT IN CASE OF SEVERE EXTERNAL BLEEDING

▸ Brings the sides of wound together & press firmly.

▸ Press on the pressure point for 10-15min.
▸ Place the causality in comfortable position & raise the injured part & reassure
him.
▸ Apply clean pad larger than the wound & press it firmly with the palm until
bleeding becomes less.
▸ If bleeding continues do not take off original dressing but add more pads.
▸ Bandage, it but not too tightly.

CONTROL OF INTERNAL HEMORRHAGE

The following methods can be used to control bleeding
▸ The organ is emptied of blood clots if possible in case of severe bleeding from
bladder, a catheter is passed & bladder is emptied.
▸ The vessels are encouraged to contact a lots of saline or sodium bicarbonate to
which a few drops of adrenaline solution have been added, is of great value in
washing the organ. This can be repeated every two hourly.

▸ The use of ergometrine after the birth of placenta is an example of stimulating

the vessel to contact pitosin IV may effective in control of bleeding from
esophageal varies.
▸ Packing it can be done with gauze soaked in adrenaline is effective.
Surgical ligature can be done in case of ruptured spleen.

FIRST AID TREATMENT IN CASE OF SEVERE INTERNAL BLEEDING

▸ Lay the causality down with head low; rise his legs by use of pillow.
▸ Keep him clam & relaxed & reassure him
▸ Do not allow him to move.
Keep up the body heat with thin blankets or coat.
▸ Do not give anything to eat or drink aspiration occure.
▸ Do not apply ice bag or hot water bag to chest & abdomen
▸ Take him to the hospital as early as possible
▸ Transport gently
NURSING MANAGEMENT
ASSESSMENT:
 Frequent nursing assessment is very important.
 Document the progress and response of the patient
 Assess blood chemistries, blood gas, oxygen saturation and electrolytes.
 Assess for the air way breathing and the circulation.
 Identify the bleeding site, amount of blood loss and nature of injury.
 Assess respiratory tract for the clearance, rate of respiration and auscultation
the respiratory sounds for any abnormality.
 and auscultation the respiratory sounds for any abnormality.
NURSING DIAGNOSIS

▸ Fluid volume deficit related to bleeding.

▸ Ineffective tissue perfusion related to bleeding.
▸ Anxiety / fear related to changes in circumstances or the threat of death.
▸ Risk for infection related to bleeding.
▸ Risk for shock; hypovolemic related to bleeding.
IMPROVE OXYGENATION:

▸ Reassure the patient and make him comfortable.

▸ Calm down the patient as anxiety may increase heart rate further causes
complications.
▸ If patient is restless, irritable never give him opiods as it may further cause
hpoxia.
▸ Clear the air way if it is obstructed with blood clots, blood or some dust particles.
▸ Turn head to one side
▸ Administer oxygen with the help of nasal canulla at the rate of 4 lit / minutes.
▸ During hypoxia patient is confused hence explain him the need of oxygenation
and the purpose of nasal cannula.

RESTORE AND MAINTAIN ADEQUATE PERFUSION:

▸ Assess the patient for the manifestation of hypoxia.
▸ Avoid hot application to treat hypothermia as it dilates peripheral blood vessels
and pull away blood from vital organs.
▸ Use modified trend burg position for the patient to increase cardiac output.
▸ Provide blanket to the patient to prevent hypothermia.
▸ Check vital signs every 5 minutes specially blood pressure and pulse.
TEMPERATURE MONITORING:
Temperature monitoring is very important in patient with shock.
▸ Check temperature by using rectal thermometer avoid axillary and oral
temperature taking.

CARDIAC MONITORING:

▸ Monitor blood pressure of the patient every 5 minutes till patients systolic blood
pressure comes to 100 mm of Hg.Check the pulse for the rate and rhythm.
▸ Monitor patients closely on cardiac monitors as patients with haemmorhagaic
shock tend to have arrhythmias due to severe electrolytes imbalance.
Measurement of CVP is important in hypovolemic shock as it helps us to prevent
fluid overload.

BLEEDING CONTROL:

▸ Assess the wound for the bleeding.

▸ Apply direct and firm pressure on the bleeding site.
▸ Inform the doctor immediately regarding bleeding.
> Prepare the patient for the surgery if required.
▸ Assist the doctor in ligation and closure of wound.
▸ Assure aseptic technique throughout the procedure, assess that wound is cleaned
properly no foreign particles are left behind in the wound.

ASSESS PATIENT FOR FLUID OVERLOAD:

▸ While treating hypovolemia often rigorous fluid therapy is given which may
cause complication such as pulmonary edema if not done carefully.
▸ Be alert for the signs and symptoms of pulmonary edema
▸ During fluid therapy assess cardiac as well as respiratory signs and symptoms
which indicate pulmonary edema. Inform unfavorable changes immediately.

PSYCHOLOGICAL SUPPORT TO THE PATIENTAND THE FAMILY:

▸ Assure the patient and his family.
▸ As anxiety increases oxygen demand by increasing the heart rate hence calm
down the patient.
▸ Keep family members informing about recent updates of patients condition and
his progress.
▸ Explain use of various equipments to the client.
▸ Explain each and every procedure prior to doing it

NUTRITION:

▸ When patient is in hypovolemia, his BMR is increased hence there is more need
of energy.
▸ Nutrition supplement is initiated as soon as possible.

BLOOD TRANSFUSION:

▸ Check the blood bag for recipients’ details, group, expiry.

▸ Tally the name of patient with blood bag.
▸ Monitor the patient throughout for any reaction.
▸ Insure that informed written consent is obtained.
▸ Keep eye on vital signs to detect reaction at early stage.
▸ Use specially designed large bore transfusion set and set the rate as per order of
physician.
▸ If reaction occurs stop the transfusion notify physician immediately.
▸ Do not live client alone during blood transfusion.
Keep monitoring the patient for any life-threatening reaction.

HEMORRHAGE SPECIAL SITES

The occurrence from special sites is designated by special term;

▸ Epistaxis-It is bleeding from nose.
▸ Hemoptysis-It is expectation of bleed from lungs
Hematemesis-It is the vomiting of bleed
▸ Melaena-It is the passage of dark blood per rectum from a site high in intestinal
tract.
▸ Hematuria-It is the presence of blood in the urine.
▸ Hemothorax-It is the bleeding in to the chest
 SHOCK

OUTLINE
1.INTRODUCTION.
2.DEFINITION.
3.CAUSES.
4.STAGES OF SHOCK.
5.CLASSIFICATION OF SHOCK.
6.FIRST AID IN CASE OF SHOCK.
7.FIRST AID IN SHOCK.
8.TREATMENT OF SHOCK.
9.MANAGEMNET OF SHOCK.
10.NURSING DIAGNOSIS.
11.COMPLICATION.
INTRODUCATION: -

The word shock is used differently by the medical communities & the general
public. The public used this term as an intense emotional reaction and medical
meaning is complex clinical syndrome & it is a life-threatening condition.
• Shock can occur in association with many kinds of major illness, such as
haemorrhage, trauma, burns, infection and heart disease.
• Haemorrhage is massive escape of blood from ruptured blood vessels either
externally (or) internally.
• Manney of the interventions required in carrying for the patient with shock
(or) haemorrhage

DEFINATION

▪ Shock is a life-threatening situation due to poor tissue perfusion with impaired

cellular metabolism, manifested in turn by serious pathophysiological
abnormalities. (Bailey and love)

■ Shock is a term used to describe the clinical syndrome that develops when there
is critical impairment of tissue perfusion due to some form of acute circulatory
failure. (Davidson's)

▪ Shock may be defined as inadequate delivery of oxygen and nutrients to maintain

normal tissue and cellular function. (Schwartz's)
*The state in which profound and widespread reduction of effective tissue
perfusion leads first to reversible, and then if prolonged, to irreversible cellular
injury. (Kumar and Parrillo, 1995)

CAUSES :-
Causes of Circulation Failure Circulation may fail
1. Sudden malfunction of heart:
This may occur as a result of
Coronary artery occlusion with acutes myocardial ischemia.
Trauma with structural damage to heart.
*- Toxemia-viral or bacterial.
• Effects of drugs.
2. Deficient oxygenation of blood in lungs
Amongst many causes the following are the most important.
*Post-operative atelectasis.
* Thoracic injuries particularly of chest, i.e. Pneumothorax, crushing and
laceration of lung
*Obstruction of pulmonary artery by an embolus.
* Disturbances of lung function following surgery and anesthesia
3. Reduction in blood volume (oligemia and hypovolemia)
This may occur from loss of.
*Whole blood -- hemorrhage (internal or external).
* Plasma-- this is particularly significant in burns.
*Water and electrolytes which occurs from peritonitis, intestinal obstruction,
paralytic ileus, acute dilation of the stomach, severe diarrheas and vomiting.
4. Miscellaneous
There are number of other conditions that may lead to shock state with low blood
pressure.
*Faintness
*Acute anaphylaxis.
*Acute adrenal deficiency (Addison's disease).
*Over dosage of drugs e.g. analgesics like pethidine.
*Following therapy with beta blocking agents.
*Noxious stimuli such as pain, if severe will cause vasodilatation particularly of
splenetic vessels with pooling of blood in the area. This is the mechanism of
primary shock.

Compensatory Mechanism
Whatever is the cause of sudden collapse; there are certain compensatory
physiological mechanisms which occur.
1.Posture: A patient in acute circulatory failure falls down; he should lie flat on
the floor or better in head down position so that circulation can be improve towards
heart.
2.contraction of skin vessels: Contraction of arterioles and venules of the skin is
usual so as to conserve the blood supply to the more vital organs.
The application of heat dilates the skin vessels there by aggravating the condition
and should not be used.
3.Insensitivity: A much collapsed patient usually has little pain. Large quantities
of pain-relieving drugs are unnecessary and are ineffective because they cannot be
absorbed unless given by intravenous route. 4.Urinary secretions: These are
diminished to conserve fluid in the body but it is also a sign that tissue perfusion is
in adequate.
5.Heart rate accelerates: It occurs in most forms of circulatory failure with the
important exception of faint. It is an attempt to ensure that remaining fluid is
circulated as rapidly as possible thereby providing sufficient oxygen to tissues.
6.Subnormal temperature: This reduces the requirements of the tissues for the
diminishing amount of oxygen available. The core temperature actually is rising.
The difference between the two is a measure of the degree of shock. All these
compensatory mechanisms are temporary in their beneficial effects and if the
condition of circulation is restored to normal without delay irreversible changes set
in.

Pathophysiology

Lack of oxygen supply and nutrient in cells

|
Cells produce energy through anaerobic metabolism to produce ATP
|
Low energy yielding from nutrients and produces acidic intracellular environment

Normal cell function affected, cells swells and cell membrane become more
permeable, allowing fluid and electrolytes to move out and into the cells

Sodium potassium pump impaired due to this

Cell structure damage

Ultimately death of cells

Stages of shock
There are 4 stages for shock
1. Initial stage
2. Compensatory stage
3. Progressive (or) (decompensate)
4. Refractory (Irreversible)

1. Initial stage

During this stage

|
Inadequate perfusion
|
Cellular hypoxia
|
Mitochondria becomes unable to produce ATP
|
Due to the lack of oxygen and the cell membranes becomes damaged.
|
Leakage to the extracellular fluid.
|
Cell performs anaerobic respiration
|
Build up of lactic and pyruvic acid.
|
Systemic metabolic acidosis.

The process of removing these components from the cells by the liver requires
oxygen (Which is absent?)

2. Compensatory stage:- This stage is characterized by the body employing

physiological mechanisms including neural hormonal and bio-chemical mechanism
in an attempt to reverse the condition in the compensatory stage of shock, the
patient's blood pressure remains with in normal limits. Vasoconstriction, increased
heart rate, and increased contractility of the heart contribute to maintaining
adequate cardiac output. This results from stimulation of the sympathetic nervous
system and subsequent release of catecholamines (epinephrine and
norepinephrine). The patient displays the often-described "fight or flight" response.
The body shunts blood from organs such as the skin, kidneys, and gastrointestinal
tract to the brain and heart to ensure adequate blood supply to these vital organs.
As a result, the patient's skin is cold and clammy, bowel sounds are hypoactive,
and urine output decreases in response to the release of aldosterone and ADH
(Anti-diuretic hormone)

Clinical manifestation
 Normal blood pressure.
 Metabolic acidosis.
 Respiratory alkalosis.
 Deep rapid respiration.
 Flat neck vein.
 Changes in LOC (Level of Consciousness).
 Irritability.
 Restlessness, dilated reactive pupil.
 Tachycardia bounding pulse.
 Dry warm skin.

Medical management

Medical treatment is directed toward identifying the cause of the shock correcting
the underlying disorder measures such as
*Fluid replacement and medication therapy.
Must be initiated to maintain the adequate BP and re-establish and maintain
adequate tissue perfusion.

3. Progressive stage (de-compensating) :-In the progressive stage of shock, the

mechanisms that regulate blood pressure can no longer compensate and the Mean
Arterial Pressure (MAP) falls below normal limits, with an average systolic blood
pressure of less than 90 mm Hg.

Although all organ systems suffer from hypo perfusion at this stage, two events
perpetuate the shock syndrome. First, the over worked heart becomes days
functional; the body's inability to meet increased oxygen requirements produces
ischemia; and biochemical mediators cause myocardial depression This leads to
failure of the cardiac pump, even if the underlying cause of the shock is not of
cardiac origin.

Second, the auto regulatory function of the microcirculation fails in response to

numerus biochemical mediators released by the zells, resulting in increased
capillary permeability with are as of arteriolar and venous constriction further
compromising cellular perfusion. At this stage the patient's prognosis worsens. The
relaxation of precapillary sphincters causes fluid to leak m the capillaries, creating
interstitial edema and return
of less fluid to the heart. Even if the underlying cause of the shock is reversed, the
breakdown of the circulatory system itself perpetuates shock state ate, and a
vicious circle ensues.

Clinical Manifestations

 Confusion.
 Dilated, sluggish pupil.
 Thirst, rapid shallow breathing.
 Tachycardia, cool moist skin.
 Slow capillary refill, muscle weakness.
 Hypotension.
Management
To restore the perfusion by following Method:

 Optimizing intravascular volume

 Supporting the pumping action of the heart
 Improving the competence of the vascular system.
 Supporting the respiratory system

4. Refractory (irreversible)
At this stage the vital organs have failed and the shock can no longer be reversed.
Brain damage and cell death will occur. Death of the person will
occur immediately.
Clinical Manifestations
 Unconsciousness, absence of reflexes.
 Dilated sluggish pupil, severe thirst.
 Acute respiratory distress syndrome,
 Disseminated intravascular coagulation, Bradycardia.
 Cyanosis.
 Absence of bowel sounds.
 Immune system collapse.
 Anuria.
 Management :-
To restore the perfusion by following Method:

 Optimizing intravascular volume

 Supporting the pumping action of the heart
 Improving the competence of the vascular system.
 Supporting the respiratory system
Classification of Shock:-
Shock can be classified according to the etiology and can be described as
1. Hypovolemic shock.
2. Cardiogenic shock.
3. Circulatory shock or distributive shock

a. Septic shock.
b. Obstructive shock.
c. Neurogenic shock.
d. Anaphylactic shock.

1. Hypovolemic shock
This is the most common type of shock, due to insufficient circulatory volume. In
hypovolemic shock there is decrease in circulatory volume to level that is
inadequate to meet body's need for tissue oxygenation. This occurs when there is
loss in the intravascular fluid upto 15% to 25%. This would represent a loss of 750
to 1300 ml of blood in a 70 kg person. Common causes of shock are: exercise,
fluid loss from circulatory system e.g. bleeding, burns, and blood loss from gastro
Intestinal or severe diarrhea.

Pathophysiology

Relative hypovolemia Absolute hypovolemia

Decreased circulating volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased cellular oxygen supply

Ineffective tissue perfusion

Impaired cellular metabolism

2. Cardiogenic shock :- It is caused by the failure of heart to pump an adequate

amount of blood to vital organs. This will lead to reduction in cardiac output. After
due damage of heart muscles, heart's ability to contract and pump blood is
impaired and the supply of oxygen is in adequate for the heart and muscles. It can
be the result of myocardial infarction. Other causes include arrhythmias,
cardiomyopathy, congestive heart failure, and cardiac valve problems.

Pathophysiology

Primary ventricular ischemia

Structural problems

Dysrhythmias

Ineffective forward motion of blood

Decreased stroke volume

Decreased cardiac output

Ineffective ventricular emptying

Increased pulmonary pressures

Pulmonary edema

Decreased oxygenation

Decreased cellular oxygen supply

Ineffective tissue perfusion

Impaired cellular metabolism
3. Circulatory shock or Distributive shock

In this there is no blood loss but the shock is due to the dilation of the blood
vessels. This displacement of blood causes a relative hypovolemia because not
enough blood returns to heart which leads to subsequent in adequate tissue
perfusion. The varied mechanisms leading to the initial vasodilatation in
circulatory shock is subdivided into septic shock. It is the most common type of
circulatory shock and caused by wide spread infection due to sepsis called by an
overwhelming infection leading vasodilatation. E.g. Infections by bacteria. They
release toxins which produce adverse biochemical, immunological and
neurological effects. The most common causative organism of septic shock is gram
negative bacteria. It is sub divided into

a. Septic shock.
b. Obstructive shock.
c. Neurogenic shock.
d. Anaphylactic shock

a. Septic Shock
Septic shock is a serious medical condition that occurs when sepsis, which is organ
injury or damage in response to infection , leads to dangerously low blood pressure
and abnormalities in cellular metabolism. The primary infection is most commonly
by bacteria, but can also be by fungi, viruses, or parasites, and can be located in
any part of the body, but most commonly in the lungs, brain, urinary tract, skin, or
abdominal organs. It can cause multiple organ dysfunction syndrome (formerly
known as multiple organ failure) and death.
Pathophysiology

Infectious toxins

Unregulated immune system activation

Vessel endothelial & platelet damage

Release of kinins, serotonin

and histamine

↑ Capillary permeability
and vasodilation

Profound CV. pulmonary and hemostatic changes

↓BP

↓Tissue perfusion

Absolute (3rd spacing) and relative hypovolemia

b. Obstructive Shock
Obstruction of blood flow results from cardiac

arrest.

E.g. Cardiac tamponade, pneumothorax, pulmonary embolism, and aortic stenosis.

c. Neurogenic Shock
This is a very uncommon type of shock. It is most often seen in patients who have
had and extensive spinal cord injuries. The loss of autonomic and motor reflexes
below level of injury results in loss of sympathetic control. This leads to relaxation
of vessels and peripheral dilation and hypotension. This is characterized by warm
and dry skin, bradycardia, rather than other type of shock.

Pathophysiology
Spinal trauma or anesthesia

Inhibit the sympathetic nerve stimulation

Psychic trauma

Fainting

Spinal cord injury

Loss of function below the level of injury

Venous vasodilation
Decrease venous return

Decreased stroke volume

Decreased cellular oxygen supply

Impaired cellular metabolism

d. Anaphylactic Shock
Anaphylactic shock is caused by severe reaction to an allergen, antigen, drug or
foreign protein. When a patient who has already produced antibodies to a foreign
substance develops a systemic antigen antibody reaction, antigen antibody
provides mast cells to release vasoactive substance such as histamine or bradykinin
that cause vasodilatation.

Pathophysiology

Due to antibody responses

Release of histamine

Vasodilatation

Increased capillary permeability

Severe broncho constriction

Decreased oxygen supply and utilization

Inadequate tissue perfusion.

Risk Factors
Immunosuppressants, invasive procedures and psychological trauma.

Diagnosis of Shock
Diagnosis of shock is essential for proper treatment and management. An accurate
history and assessment of patient symptoms must be done before commencing
treatment.
*Conducts head to toe examination for signs of shock.
*Assess neurological status of the person by assessing the level of consciousness.
*Assess the cardiovascular status. Blood pressure varies with the stages of shock.
*Assess for renal status. Anuria and renal failure can occur.
*Assess for integumentary status. Check for skin color, cold and clammy skin,
cyanosis.
*Assess gastro intestinal status. Hypo active bowel sounds.
*Assess for the metabolic status. Metabolic acidosis will be there.

Diagnostic Studies
Blood studies reveal overly acidic blood PH with low circulatory carbon dioxide,
blood pressure monitoring.

First Aid in Case of Shock

Principles Involved In First Aid
1. Remove the cause of accident from near the causality. If possible remove
the causality from danger such as burning house, room with poisonous
gases.
2. Handling the patient with due care and attention to reduce pain and to
prevent worsening of the condition.
3. Constant observation should be provided the causality to identify failure of
breathing, bleeding and then to take appropriate measures to treat problems.
4. Using material available at hand.
5. Clear the crowd around the causality.
6. Take the help of the by standers to give firs
7. Reassure the causality.
8. Transport the causality to the doctor as early as Possible
First Aid in Shock
 Reassure the causality.
 Lay him down on his back comfortably with head low and turned to one side
except in case of head injury.
 Loosen the clothing around the neck, chest and waist.
 Keep the causality warm.
 Give him sips of water if he is thirsty. Never any alcoholic drinks.
  Never use hot water bag or massage the limbs.
 Arrest hemorrhage by adequate measures.
 Check pulse, respiration and level of consciousness.
 Transport the causality to the hospital immediately.
Treatment of Shock
Pharmacological interventions:

1. Hypovolemic shock
 Volume expanders
 Desmopressin (in case of diabetes)
 Antidiarrheal agents for diarrhea
2. Carcinogenic shock

 Volume expanders
 Positive cardiac ionotropic
 Vasodilators
 Vasoactive and antiarrhythmic medication

3. Distributive shock

 Volume expanders
 Positive cardiac ionotropic agents
 Vasoconstrictors

4. Obstructive shock
 Volume expanders
5. Septic shock

 Broad spectrum antibiotics

6. Neurogenic shock

 Hypoglycemia-glucose is rapidly administered.

Management of Shock

Administration of intravenous fluids, blood products, and medication. They are

helpful in treating shock.
These include

. Crystalloids: These are used for intravenous fluid replacement in early stages of
shock.e.g. ringer's solution and normal saline most commonly used.

Ionotropic agents: Like dopamine, dobutamine and epinephrine to improve

myocardial contractility, adequate cardiac output and improve tissue perfusion.

- Vasodilators: Nitroglycerine, sodium nitroprusside used to dilate the coronary

arteries. Diuretics: These are used to treat oliguria and increase urine output.
Antibiotics: Used to treat septic shock because they are bactericidal.

Antihistamines: Epinephrine used in an aphylactic shock.

Steroids: Used to decrease fluid shifts out of vasculature by stabilizing capillary

walls.

Sodium bicarbonate: It is used to treat metabolic acidosis that occurs as shock

progress.

Bronchodilators: Like atropine, aminophylline, used to relieve bronco

constriction in case of an aphylactic shock.

Nursing Management in Case of Shock:-

 Maintain ABC of the patient.
 Provide supplemental oxygen therapy to the patient.
 Do not deliver more than 2 lt. of oxygen per minute if person has
history of chronic pulmonary disease.
 Monitor for ABG value to assess the patient response to oxygen
therapy. Continuous monitoring of vital signs should be done.
 Check for urine output of the client.
 Maintain nutritional status of the patient.
 Maintain nutritional status of the patient.
  Administer prescribed medication to the patient.
 Give psychological support to the patient and the relatives.

Nursing Diagnosis in Case of Shock

1. Fluid volume deficit related to hemorrhage.

Nursing interventions:
 Monitor the signs and symptoms of internal bleeding.
 Check for blood pressure.
 Give comfortable position. Keep the patient warm and monitor temperature
hourly.
 Administer intravenous fluids as ordered.
 Monitor urine output.
 Administer oxygen as ordered.
2. Decreased cardiac output related to ineffective cardiac function.

Nursing interventions:
 Administer IV fluids
 Monitor urine output.
 Monitor blood pressure and pulse rate.
 Administer ionotropic agents to correct ventricular function.

3. Risk for infection related to interruption of skin integrity from invasive

procedures.

Nursing interventions

Take precautions to prevent nosocomial infections.

a. Wash hands frequently.
b. Use aseptic techniques.
c. Monitor sites of insertion for signs of infection.
d. Change the intravenous catheter every three days.
e. Provide indwelling catheter care frequently.
f. Monitor for white blood cell count for elevation greater than 10,000 cells per
mm3.
4. Altered nutrition less than body requirement related to decrease oral
intake.

Nursing interventions:
 Monitor daily weight and identify weight loss.
 Consult nutritionist for recommendations about diet.
 Check for gastric residuals every 4 hourly; notify the physician if it is greater
than 100 ml.
 Monitor for hematocrit, hemoglobin to assess the adequacy of nutritional
replacement.

5. Altered peripheral tissue perfusion related to edema from stasis of blood in

the capillaries and vasoconstriction.

Nursing interventions:
 Monitor the extent of fluid retention.
 Monitor daily weight of the patient.
 Determine the severity of edema.
 Watch for elevation in central venous pressure.
Prevention of Shock /
Preoperative Measures
 Circulatory collapse should be assessed by strenuous measures if at all
possible. Preoperatively the patient should be as fit as possible and from the
point of vie from circulatory system.
 His blood should be adequate in quantity and volume.
 His tissues should be adequately hydrated.
 He should be mobile so that there should be no stagnation in the circulatory
system.
 Patient should be kept warm on his journey from ward to theatre.

Post operatively

Fluid and electrolyte replacement should be done with normal saline, dextrose 5%,
plasma and rest and relief from the pain continues.
Gentle handling by nursing staff will help in prevention of shock.
Diuretics like mannitol an osmotic diuretic which is neither absorbed in the renal
tubules nor metabolized. If oliguria persists frusemide can be given. Dopamine can
be given to improve blood pressure.

Complications :-

a. ARDS- (acute respiratory distress syndrome)

In case of septic shock patient may go for ARDS or DIC - disseminated

intravascular coagulation due to in effective perfusion and decrease venous return

b. Multiple Organ Failure

Due to inadequate tissue perfusion and decreased venous return multiple organ
failure occurs.

SUMMARY: Today I have discussed about hemorrhage its classification, clinical

features, hemorrhagic disorders and management in detail and shock definitions,
pathophysiology, stages, classification of shock, clinical features, emergency
management, medical and surgical management and nursing management and
prevention in detail.
CONCLUSION: Shock is critical condition with a high mortality rate early
diagnosis and prompt intervention are necessary for the best possible outcomes.
Shock is preventable one if it is recognized in time, and treatment is imitated as
early as possible. As nurses we are person who will be spending more time with
the giving care. We are the persons who can save their lives if hemorrhage and
shock are recognized and treated with our best knowledge.

BIBLIOGRAPHY:

1. Ross and Wilson "Anatomy and physiology health and illness", 9th edition,
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3. Baillier's Nurses Dictionary edited by Brabara, F. willer, 23rd edition.
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clinical problems", 6th edition, (2004), mosby publications.
5. Suzan C. Smeltzer, Barrenda. G. Bare (1996) Brunner and suddarths "Text book
of medical surgery nursing", 8th edition, Pennsylvania, lippincott raven
publication.
6. D.C. Dutta "A text book of obstetrics", 6th edition, page no: 342, 344.
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f&oq=&aqi=g10&start=0